Monday Monitor

August 25, 2014

Update: Settlement Conference Facilitation Project

Why is this important, this facilitation process? Particularly, we know a lot of our listeners are health care facilities. Why is it important to health care facilities when at this time the facilitation program is limited to Part B? There are really a couple of main reasons. One, the facilitation process. You know, when we have health systems, what we have found that they have physicians that are employed that are getting audited, laboratories, DME. We have three facilitations in process right now. One of them is in fact a health system on their Part B claims. Another reason is, I think this is a very important reason, is to get experience in this process. There is something in the works going on that we think that will apply a facilitation-type process to Part A sooner than later so I would say stay tuned to that because we may see this applied to Part A with the volume of claims that we have in the relative near future.

Now, I’ve had some communications with OMHA regarding the process to get a feel for our clients and there’s a couple I think of important factors. The first one that was really encouraging is that once this is filed, and we have filed two out of the three, we’re completing the third process for filing, they anticipate having a facilitation conference and resolution within 90 days. So while the rest of providers and appeals are waiting for three years or more to get their hearings, we’re talking about a resolution of 90 days. That should incentivize providers to participate. If you want to do this in person, you’re probably going to have to go to Washington D.C. We don’t know. CMS is going to be the party on the other side. They may delegate it to contractors, but right now it looks like it is CMS that is making this decision. There is something advantageous about doing it in person or even videoconferencing because in the mediation process some of the research shows that 50% of communication generally is non-verbal and being able to get a sense of where CMS is in the resolution process could be important just to kind of look for those non-verbal cues.

Another interesting component that OMHA shared with me is that they anticipate having an initial kind of pre-facilitation conference to set the ground rules, the timing. But they anticipate the parties to actually engage in communications before the settlement conference in order to hopefully by the settlement facilitation time that the parties may be able to put their agreement on the record. So, these are some of the, I think, interesting aspects of it that may make it just traditional information. Another tip, the settlement conference facilitation spreadsheet is somewhat time-consuming to fill out. It’s not that it’s difficult, but it just takes some time to go by line by line on an excel spreadsheet and one of the things that we found is that not all of the information is always readily available to the appeal. So there’s a column for the claim adjustment reason code, the reason for the denial in Part B. That is not always available. They have told us, I would take this as general advice, but they told us that we can submit it without it and get that information later.

Finally, a couple of things for mediation. Be prepared. Research your case. Use a mediation opening statement to articulate your position. Understand the position on the other side. Look for where leverage is. CMS’ interest is to clear out the appeals process. Make your case. The settlement facilitation agreement takes place at the time of the facilitation.